Campbell Ashley M, Coley Kim C, Corbo Jason M, DeLellis Teresa M, Joseph Matthew, Thorpe Carolyn T, McGivney Melissa S, Klatt Patricia, Cox-Vance Lora, Balestrino Vincent, Sakely Heather
Assistant Professor, Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson.
Professor, Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, PA.
Am Health Drug Benefits. 2018 Dec;11(9):469-478.
Drug therapy problems, which are adverse events involving medications that can ultimately interfere with a patient's therapeutic goals, occur frequently in older adults. If not identified, resolved, and prevented through clinical decision-making, drug therapy problems may negatively affect patient health outcomes.
To quantify the impact of pharmacist interventions on the care of older adults by identifying the most common drug therapy problems, the medications most often involved in these problems, and the actions taken by pharmacists to resolve these problems.
This retrospective chart review included individuals seen by a geriatric pharmacist in one geriatric practice, where 4 pharmacists provide continuous, comprehensive medication management across 2 outpatient geriatric clinics, skilled-nursing facilities, and assisted-living facilities. The individuals were seen between August 2014 and November 2015. For all patient care encounters during this time frame, pharmacists used the Assurance System to document each drug therapy problem, the medications involved, the patient's care setting (ie, outpatient clinic, assisted-living facility, skilled-nursing facility), the actions taken to resolve any drug therapy problems, and the estimated 90-day impact on the patient and the healthcare system.
A total of 3100 drug therapy problems were identified during 3309 patient-pharmacist encounters for 452 patients (mean age, 81.4 years), 48.7% of whom were seen in the skilled-nursing facility. The most common drug therapy problem was dose too low, followed by dose too high, and warfarin was the most common drug associated with drug therapy problems. Pharmacists provided 4921 interventions, often more than 1 intervention per drug therapy problem, for 275 different medications. Laboratory monitoring and dose change were the most common interventions, with an estimated annual financial savings between $268,690 and $270,591.
Older patients are a vulnerable patient population who often receive unsafe medication regimens, which can result in adverse drug reactions and other critical problems. When integrated into interprofessional geriatric care teams, pharmacists' interventions provide an invaluable qualitative and monetary resource to the medication-based management of patients with well-recognized, high-risk geriatric syndromes as they transition to and through various levels of care.
药物治疗问题是指涉及药物的不良事件，最终可能干扰患者的治疗目标，在老年人中频繁发生。如果不通过临床决策识别、解决和预防，药物治疗问题可能会对患者的健康结局产生负面影响。
通过识别最常见的药物治疗问题、这些问题中最常涉及的药物以及药剂师为解决这些问题所采取的行动，量化药剂师干预对老年人护理的影响。
这项回顾性病历审查纳入了一家老年医学诊所中由老年药剂师诊治的患者，该诊所的4名药剂师为2家门诊老年诊所、熟练护理设施和辅助生活设施提供持续、全面的药物管理。这些患者于2014年8月至2015年11月期间就诊。在此时间段内的所有患者护理接触中，药剂师使用保障系统记录每个药物治疗问题、所涉及的药物、患者的护理环境（即门诊诊所、辅助生活设施、熟练护理设施）、为解决任何药物治疗问题所采取的行动以及对患者和医疗保健系统的估计90天影响。
在452名患者（平均年龄81.4岁）的3309次患者 - 药剂师接触中，共识别出3100个药物治疗问题，其中48.7%的患者在熟练护理设施就诊。最常见的药物治疗问题是剂量过低，其次是剂量过高，华法林是与药物治疗问题最相关的药物。药剂师针对275种不同药物提供了4921次干预，每个药物治疗问题通常进行不止1次干预。实验室监测和剂量调整是最常见的干预措施，估计每年节省资金268,690美元至270,591美元。
老年患者是弱势群体，经常接受不安全的药物治疗方案，这可能导致药物不良反应和其他严重问题。当药剂师融入跨专业老年护理团队时，他们的干预为患有公认的高风险老年综合征的患者在过渡到不同护理级别并在这些级别接受护理期间基于药物的管理提供了宝贵的质量和资金资源。
